THE IMPACT OF EMPLOYEE TURNOVER — HEALTHCARE

ASSISTANTS IN DUBLIN, IRELAND.

BY

IBEABUCHI ARUA KALU

STUDENT NO: 18137211

IN PARTIAL FULFILMENT FOR THE AWARD OF M.A. HUMAN

RESOURCE MANAGEMENT.

NATIONAL COLLEGE OF IRELAND, DUBLIN

i

DECLARATION

I declare that this academic work has been carried out by myself. All referenced materials from secondary

sources have been properly cited. *I declare that no material contained in the dissertation has been used in

any other submission for an academic award.

Signature of research student: Kalu, I. A.

Date: 19/08/2020

ii

ACKNOWLEDGEMENT

I would first like to thank the almighty God for his grace in me. Secondly, I would like to thank and

acknowledge my supervisor, Dr. T. J. McCabe at National College of Ireland for his expertise,

commitment, patience and guidance throughout the process of writing this thesis. Without his help, this

study could have never been possible. I would also like to extend my sincere thanks to the NCI staff; the

lectures, IT department and specially the Library team for their continued support, passion and

commitment to the learning community. It could have not been possible without them.

Moreover, a sincere gratitude to all the participants who made this possible, the management of the

three nursing homes used who trusted me enough to give their permission and time in using their

employees and all that I needed for the use of my studies. Without them the research could have never

been possible to undertake. Furthermore, the unconditional support, passionate encouragement rendered

by my partner Rory Moore and his beloved family no words could ever express my most profound

gratitude and appreciation.

I also like to express my heartfelt gratitude to my friend, Dr. Sean Xavier Laurence for his

contribution throughout my thesis.

Finally, and most importantly I would like to extend a sincere appreciation to my dearest family

members: my parents and siblings, and my in-law (Peter Elofusim), for their full financial support. To my

friends: Dr. Timothy and Tobi, I thank you dearly for being a pillar of motivation and strength throughout

my dissertation. I thank you all from the bottom of my heart. This dissertation is dedicated to you all.

iii

DECLARATION

A. I declare that this work submitted has been composed by myself.

B. I declare that all verbatim extracts contained in the thesis have been distinguished by quotation

marks and the sources of information specifically acknowledged.

C. I agree to my thesis being deposited in the NCI Library online

open access repository NORMA.

D. Either *I declare that no material contained in the thesis has been

used in any other submission for an academic award.

Or *I declare that the following material contained in the thesis

formed part of a submission for the award of

____________________________________________________

Signature of research student: Kalu, I. A.

Date: 19/08/2020

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TABLE OF CONTENTS

Cover page

Declaration i

Acknowledgement ii

Dedication iii

List of Figures vii

List of Tables viii

List of abbreviations ix

Abstract x

CHAPTER ONE……………………………Main Introduction

1.1 Purpose of the study 1

1.2 Research objectives 1

1.3 Research problem 2

1.4 Context to the study 4

1.5 Health care assistants 7

1.6 Roles and working conditions of HCAs 8

1.7 Turnover and absenteeism among health care assistants 8

1.8 The significance of the study 10

1.9 Structure of the research thesis 11

CHAPTER TWO…………………………Literature Review

2.0 Introduction 12

2.1 Defining the Nursing Home Care 12

2.2 Job satisfaction 13

2.3 Employee turnover 14

v

2.4 Causative factors of employee turnover 15

2.5 Implications of employee turnover 17

2.6 Employee engagement 17

2.7 Employee motivation 18

2.8 Working condition 19

2.9 Two-factor theory 21

CHAPTER THREE…………………………Methodology

3.2 Introduction 24

3.3 Methodological approach 24

3.3 Research approach 25

3.4 Validity and reliability of the measuring instrument 26

3.5 Study site 27

3.6 Population 27

3.7 Sample size 27

3.8 Data collection 28

3.9 Data analysis 28

3.10 Conclusion 29

CHAPTER FOUR……………………………Result and Analysis

4.1 introduction 30

4.2 research question 31

4.3 data preparation and analysis 31

4.4 results | bio-data 48

CHAPTER FIVE……………………………Discussion and summary

5.1 Discussion and summary 53

5.2 Recommendations 55

vi

5.3 Challenges and limitations of the study 56

5.5 Reflection/personal learning statement 56

5.5 Ethical considerations 58

5.6 Conclusion 58

APPENDIX

1.0 Questionnaire survey 59

REFERENCES 62

vii

LIST OF FIGURES

Figure 1A showing care company type

Figure 1B showing employment length

Figure 2: A pie chart of respondents’ age

Figure 3: A bar chart representation of respondents’ gender group

Figure 4: A stacked bar chart of age range and gender

Figure 5: Job type mapped against nationality

Figure 6: Questionnaire Item 7 (Q7)

Figure 7: Questionnaire Item 8 (Q8)

Figure 8: Questionnaire Item 9 (Q9)

Figure 9: Productivity and work-related stress

Figure 10: Visual representation for gender and covid-19 work-related stress

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LIST OF TABLES

Table 1: Other socio-demographic bio-data

Table 2: Frequency distribution of respondents’ age range

Table 3: Frequency distribution of respondents’ gender group

Table 4: Crosstabulation of age range and gender

Table 5: Crosstabulation of nationality and job type

Table 6: Two-way Pearson chi-square test

Table 7: Kendall’s tau b correlation coefficient for Q7, Q8 and Q9

Table 8: Questionnaire item 13 indicating level of job satisfaction

Table 9: Questionnaire item 15 indicating level of job motivation

Table 10: Spearman’s rho correlation between job satisfaction and job motivation

Table 11: Kendall’s correlation between productivity and work-related stress

Table 12: Descriptive statistics for gender and covid-19 work-related stress

Table 13: Spearman’s rho correlation test between gender and COVID-19 work-related stress

Table 14: Mean and standard deviation for Q20, Q21 and Q22

Table 15: Mean ranks of Q20, Q21 and Q22

Table 16: Kruskal-Wallis H test statistics for Q20, Q21 and Q22

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LIST OF ABBREVIATIONS

CNAs.............Certified nursing assistants

HCAs.............Health care assistants

RNs……….. Registered nurses

HSE.............. Health Service Executive

GWB............ General well – being

CIPD........... Chartered Institute of Personnel and Development

NCI............. National College of Ireland

HRM........... Human Resource Management

NHS……… National Health Service

DoHC……..Department of Health and Children

WRQoL………Work-related quality of life

COVID-19………Corona Virus Disease 2019

PMMH……… Patient Movement Manual Handling

CSO………. Central Statistics Office

HR……… Human resources

SPSS……… Statistics Package for the Social Sciences

RQ……… Research question

x

ABSTRACT

This study aims to assess the impact of employee turnover among healthcare assistants in Dublin,

Ireland. The path taken to the task at hand was to approach the topic by discussing the subject matter

itself, while noting the nature of their job task. The care facility at which these Healthcare assistants work

for are equally discussed specifically.

This study will look deeper into the critical impacts of staff shortages which in this case is the high

turnover. The high turnover in the sector is the underlying problem which needs addressed. Additionally,

the study will investigate possible efforts of retention strategies in order to curb the increased turnover

rates within the private nursing homes. The study will investigate possible efforts of retention strategies in

order to curb the increased turnover rates within the private nursing homes.

To explore turnover and retention of nursing assistants, the research study was conducted within the

quantitative method, using a cross-sectional survey design. The objectives of this study were to establish

if there are any notable differences in turnover rate levels between age groups, gender and nationality,

suggest most effective measures for implementation by management to improve the turnover amongst.

It is found that majority found their job be very stressful and noted that their workloads has gotten

even more stressful amidst the COVID-19 global pandemic. More than two-thirds (a total of 80%) agreed

or strongly agreed that their job had more advantages than disadvantages. Deeper in the study reveals that

majority of the respondents were not satisfied with their job. In the same vein, they responses shows that

stress management, Talent management and development, work-life balance and employee engagement

serve as the vital indicators for retention.

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CHAPTER ONE

MAIN INTRODUCTION

In recent times, academic research works have been carried out which is aimed at addressing certain

possible Human Resource related problems affecting the healthcare sector. It is not breaking news that the

sector has been challenged with absenteeism and reoccurring high turnover among the entire healthcare

workers. The Healthcare sector is vital in any given country; this therefore, is the driving force behind

finding out the strongest predictors of turnover and establishing the push factor of turnover undermining

Healthcare Assistants (HCAs) in particular.

1.1 PURPOSE OF STUDY

The purpose of the study is to assess issues of employee turnover for healthcare assistants working in the

care industry in Dublin, and how the impact of this issue on Irish healthcare sector. Allutis et al (2014)

admitted that there is a rise in the level of job turnover among care professionals in Europe due to several

unfavorable working conditions and other personal grievances, and so it is therefore important to retain

their existing staff and attract new workforce in the sector. This study will add body of knowledge to

existing research studies.

1.2 RESEARCH OBJECTIVES

The following are the research objectives to be addressed:

i. To examine if there is any evidence that African nationals make up a larger proportion of HCA

temporary staff working in Dublin

ii. To examine the differences in perceptions towards COVID-19 pandemic between male and

female healthcare assistants in Dublin

iii. To examine the degree at which staff motivation influence job satisfaction among HCAs

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iv. To weigh the degree at which a decline in job productivity is correlated with work-related stress

among the HCAs

v. To determine whether staff turnover leave any detrimental effect on existing staff and the

workplace

vi. To weigh the relationship amongst payments and benefits, work-life balance and favorable

workload on job satisfaction between male and female HCAs working in Dublin

1.3 RESEARCH PROBLEM

Even though the problem of high employee turnover rates among HCAs in the Irish nursing homes

have been extensively explored, in the wake of the current global COVID-19 pandemic, very little is

known about how this and other factors may be contributing to high HCA turnover in Dublin, Ireland.

Also, the fact that there is a growing life expectancy rate in Ireland which has caused a spike in the

demand for health care assistants has made the issue of “HCA staff high turnover” an important issue to

be talked about (Spilsbury, 2013). Moreover, the constant changes to the personnel, a response often

facilitated by management to fill the void left by HCAs who have quit, can negatively impact the

residents of these care homes or nursing homes; some found it difficult to adapt to these changes; for

others their neurological and mobile ailments often meant that they tended to prefer to be cared for by one

HCA over another (Care of the elderly, 2020, Drennan et al, 2018).

Healthcare services in general need to be very updated in order to achieve the optimum goal of a

healthier nation. To retain the existing and attract the future generations into the healthcare industry, job

satisfaction is very vital to attain this; it impacts on the productivity of healthcare workers and also serves

as a measure for healthcare quality improvement programs. Low job satisfaction, on the other hand, may

result to increased and reoccurring turnover, reduction in efficiency and productivity, thus poor delivery

of healthcare duties to the vulnerable residents. (Lonnie Golden, 2011).

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Among the factors noted by previous research is stress. The health care staff are considered to

provide the quality care in a stressful working environment; job satisfaction is therefore necessary

(Pembrooke, 2017). The National Institute for Occupational Safety and Health (NIOSH, 2008) defines

occupational stress as “the harmful physical and emotional responses that occur when the requirements of

the job do not match the capabilities, resources, or needs of the worker.”

The European Union has noted how significantly important is the standard quality for service-

delivery and quality aspects of work as several companies regularly conduct their own job satisfaction

surveys e.g., Denmark. Moreover, some European countries came up with employee satisfaction index

which indicates the real importance of satisfaction at work and improving job quality to promote

employment and social inclusion (European Commission, 2002).

As the primary purpose of this study is to comprehensively assess all possible factors that are

affecting HCAs in nursing home and care home companies today in Dublin, the study will therefore look

at how satisfied HCAs feel about their work; it will also assess the conditions they work under.

As several factors abounds, the issue of high turnover is key and would be looked into firstly. While

carrying out this research, insights would be derived from healthcare assistants in three nursing homes in

Dublin, Ireland. Emphasis will be on determining whether lack of motivation could be attributed as being

a major cause of dissatisfaction on the part of HCAs.

As retention rate is one of the yardsticks to measure the success of any workplace, it is only right to

expect care companies to be doing enough to drive those numbers up, while comprehensively looking into

all possible factors that may be affecting the working conditions in their organization (Daft, 2014; Hitt et

al, 2016). The hope for this research therefore is that by recruiting HCAs currently deployed in these care

homes or nursing homes, tremendous insights could be derived which would help explain what needs to

be facilitated to improve the rate of employee retention.

This chapter therefore provides the overall context to the study. It sets out the motivation for the

study, its’ objectives, the significance and scope of the present investigation. A couple of other titles

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would be used interchangeably in this thesis to describe health care assistants (HCAs); titles like: care

professionals, nursing assistants, care support workers, carers, etc. The findings in this study could

contribute to positive social change by reducing turnover intention while improving the quality of care

and reducing costs of care that affect the lives of the long-term care residents, concerned family members,

and significant others.

1.4 CONTEXT TO THE STUDY

The Irish health care sector has suffered a setback in recent times as a good number of healthcare

workers had quit; some relocated to countries they felt offered them more favorable terms. Nurses and

health care workers overwhelmed by the sheer number of tasks they need to complete are quitting their

roles. Management and human resource managers have a key role to play to reduce high staff turnover.

More so the human resource team are tasked with looking after the entire workforce, ensuring the

organization is suitably staffed, and that staff are well-treated.

Indeed, employees are an important asset to every company, business and organization as they are

the nucleus and engine of the workplace (Price, 2004; Kew and Stredwick, 2013). It has often been

regarded that having the right employees is integral to and constitute the most important part of any

organization; employees are in fact the foundation of any business; therefore, they constitute the most

valuable asset of the business (Taylor, 2014). As such, having good employee services, and good

employee well-being and people management policies and practices is critical, without which, there

would be an increased level of dissatisfaction among employees (Armstrong and Taylor, 2017). Similarly,

a healthy culture of training programs, and employees perks and incentives like: performance cash

bonuses, gift certificates, company cars to workers and many more, have all been identified as possible

ways to boost employee retention, and reduce staff turnover more specifically (Samuel and Chipunza,

2009; Milcovich et al (2001).

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A wide range of factors impacts on the working condition of healthcare assistants working for care

companies in Dublin. These factors could be internal or external:

a) Socio-cultural factor:

Statistics show an aging population of Irish nationals; this is a social factor that needs to be

addressed. The rise in this demographic continues to drive the demand for provision of quality care homes

for the elderly population. Likewise, as the aging population grows the demand for care professionals to

work in these care homes invariably increases. Social factors like income, stress levels, work hours, and

work environment could well affect the working conditions as well as a HCA’s commitment towards

work in general (Cavendish, 2013, Spilsbury et al., 2013, Estabrooks et al., 2015, UNISON, 2016).

There are many factors (job stressors) that can lead to stress and dissatisfaction among health care

workers such as, Job or task demands (work overload, lack of task control, role ambiguity),

Organizational factors (poor interpersonal relations, unfair management practices), Financial and

economic factors, Conflict between work and family roles and responsibilities, Training and career

development issues (lack of opportunity for growth or promotion), Poor organizational climate, or lack of

management commitment to core values and conflicting communication styles, among others

(Pembrooke, 2017) There have been suggestions that the social factors when not managed appropriately,

could contribute to about 40 percent of an individual’s attitude towards work.

b) Technological Factor:

It is a generally accepted opinion that technology would influence the way health care services are

rendered (Thimbleby, 2013). However, outdated technologies and processes create challenges across an

overburdened health care system. If appropriate technological interventions are not introduced, chances

are the exasperated situation might result in high stress levels on care professionals, and inferior outcomes

(ibid). For instance, increasingly seen as outdated equipment, hoist systems used for transporting patients

still presents a better option — as opposed to the Patient Movement Manual Handling (PMMH); hoists

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reduce unnecessary strain on carers and it may help save them from damaging their vertebra columns

when taking their patients with severe mobility condition in and out of bed.

c) Economic Factor:

Health care assistants are listed among low-skilled professions (CS0, 2018). Governments promotes

wellbeing of workers and aid organizations by stimulating economic development through subsidizing

selected sectors, giving tax advantages in certain situations and even supporting research and

development. The level of government budget and expenditure on health, and the financial resources it

pushes into this sector may impact on the working conditions of HCAs (Kessler, 2015; Cooke and

Bartram, 2015). A low government budget on health might cause a decline in the quality of care provided

for patients; this could in turn create unfavorable working conditions for care professionals (Cooke and

Batram, 2015).

d) Environment Factors:

Just as the environmental safety and quality of care for the patients and care home residents are

considered to be important, the same should be extended to care workers. Care workers are constantly

being exposed to possible communicable diseases in their work environment, especially during outbreaks

of influenzas, bugs and other major epidemics. A case in point is the ongoing Corona Virus (covid-19)

pandemic that has claimed the lives of many healthcare workers in Ireland and globally (Murphy, 2020).

Care professionals risk exposures to possible communicable diseases from the constant travels they make

from one patient home to the next while using public transportation (ibid). A well-reasoned argument can

thus be made to say that environment factors too can impact on the work and working conditions of

HCAs.

e) Political/Legal Factors:

A greater percentage of care professionals in Ireland are foreign nationals (CSO, 2018), majority of

whom are international students. From a legal standpoint, many of these foreign students may be required

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to leave the country immediately they complete their study programs or when their student visas expire,

notwithstanding the relevant care experience they have gained working for care homes in Ireland.

Barring any changes, with the current trajectory, a higher turnover among “temporary” care

professionals in Ireland is projected (Smith et al, 2019). One might even envisage the possibility of a

further drop on the availability of these temporary care professionals especially in circumstances where

there is a drop in the number of international students enrolling to study in Ireland. However, a more

lenient immigration policy for temporary care professionals might help to halt the decline in the

availability of HCAs.

1.5 HEALTH CARE ASSISTANTS

The HCA profession is similar to the nursing profession (Braeseke et al., 2013). Heath care

assistants offer in-person face-to-face care of a personal nature to patients in clinical or therapeutic

settings, community facilities or domiciliary settings (Saks et al., 2000; International Labor

Organization); they may not even hold a professional license or relevant qualifications from regulatory or

accredited bodies (ibid). Typically working under the direction and supervision of registered healthcare

professionals, HCAs often possess the skills of addressing the basic care needs of individual patients

(NHS Scotland, 2010).

In Ireland, The Department of Health and Children (DoHC., 2001), have defined the role of the

HCA as: to assist nursing/midwifery staff in the delivery of patient care under the direction and

supervision of either the Clinical Nurse Manager, Staff Nurses, Midwives, Public Health Nurses or even

community Registered General Nurse as appropriate.

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1.6 ROLES AND WORKING CONDITIONS OF HCAs

Research shows that the elderly who are committed to nursing care homes are looked after there by

two categories of nurses: a registered nurse (RN), or a certified nursing assistant (CNA) / HCA. Tasks

undertaken by HCAs/CNAs are multifaceted; a HCA’s role is continually expanding.

In describing their roles, Pélissier et al (2018) explains that a registered nurse offers mainly

technical care; an assistant nurse bears the greater burden of the direct care for patients/residents. Kessler

et al. (2010) highlighted the evolving role of the HCA; according to them, as the bedside technician, a

HCA is often tasked with delivering fundamental care to patients. In their view, the role of HCAs has

increasingly expanded into more technical tasks that were previously under the remit of RNs.

Cavendish (2013) prefers the categorization of HCA roles into: routine tasks (e.g. making beds,

helping patients with nutrition, cleansing and dressing, blood glucose monitoring, vital sign observations,

simple wound dressings and transporting patients) and advanced tasks which were traditionally under the

remit of RNs (e.g. female catheterization, intravenous cannulation, complex wound care, infusion feeding,

preparation, ECG recordings, phlebotomy and care planning).

Typically, health care assistants (HCAs) are further categorized into formal (involuntary) workers,

and informal (voluntary) workers; these are based entirely on whether or not a HCA staff is paid for their

services. A formal HCA type-work refers to care services done in return for a wage or remuneration; an

informal HCA type-work is care work performed for non-profit making purposes. The present study is

wholly aligned with the formal HCA definition; the scope of the present study will cover HCAs working

at care homes and nursing homes.

1.7 TURNOVER AND ABSENTEEISM AMONG HEALTH CARE ASSISTANTS

The impact of the current COVID-19 global pandemic caused many health care assistants to quit

their jobs over safety fears. Employee turnover more generally, concerns the rate of workers who quit a

company for another within a particular period of time (Taylor, 2019). Reoccurring turnover would mean

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that nursing homes companies are continually faced with the prospect of hiring and training of new staff

to replace the ones that have left. These staff replacement exercises have significant cost implications

(ibid).

As Pilbeam and Corbridge (2010) succinctly put, turnover has to do with “the percentage of

employees of an organization who left in a particular period of time”. Retention on the other hand is the

calculated effort by an employer to keep desirable workers in order to meet the target of the business, by

ensuring the right people are positioned with the right jobs tasks (ibid). Successful companies often have

high employee retention rate.

employee turnover can be viewed from two broad categories (Lee et al., 2017) . With regards to this

definition, employee turnover is termination of work relationship or leaving your profession altogether

whence bringing us to the realization that this termination can be voluntary or involuntary. Research has

turned out that voluntary employee turnover generally refers to the state of an employee leaving an

organization by their own volition (Rubenstein, Eberly, Lee, & Mitchell,2018) while involuntary

employee turnover is when an employee’s job contract is terminated or instituted by the employer (Lee et

al., 2017). This form of turnover is also referred to as firing or discharge (Kammeyer‐Mueller, Wang, and

Thundiyil, 2019). It’s involuntary because it is not the employee’s decision to leave the company. The

termination can be caused by for reasons such as undesirable job performance, absenteeism or non-

obedience of workplace policies (Rubenstein et al.,2018).

Swarnalatha and Sureshkrishna (2013) define absenteeism simply as the "failure to report to work"

and noted that employees who regularly or habitually absent from their workplace are a threat to the

workplace. Senel and Senel (2012) take a more measured approach, defining absenteeism as the "lack of

presence of an employee for planned work".

On the issue of absenteeism, lower levels of quality care have also been attributed to the rise in

absenteeism among HCAs. A large-scale study by Castle and Ferguson-Rome (2015) found there to be an

average of 9.2% absenteeism amongst HCAs in the nursing sector in the USA. Also, compared to all

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other occupations, HCAs working in the US were found to have the highest absenteeism rates due to

work related injuries (Baughman and Smith, 2012).

And of those in the US who left an HCA employment, only a third stayed within the sector (ibid).

Amongst CNAs working in the nursing home sector in the US, ‘supportive supervision was a significant

factor for job satisfaction (Choi and Johantgen, 2012). With increase in supportive supervision, CNAs are

said to be: “4.09 times more likely to be satisfied with their jobs and 47% less likely to intend to leave

their jobs” (Gruss et al, 2004).

1.8 THE SIGNIFICANCE OF THE STUDY

This research is of great significance as it will identify the various reasons why there are high

employee turnover rates in care homes and nursing homes across Ireland. In particular, this research

output would benefit management and human resource (HR) managers of nursing homes, and other

healthcare facilities like hospitals, blood banks, mental health and addiction treatment centers, hospice

homes etc. in Ireland. The hope is that this research output will help these organizations identify ways to

substantially reduce employee high turnover rate thus boosting their cost-saving gains from not constantly

having to replace and train new employees.

Naturally, this situation would benefit HCAs too, as organizations will be forced to focus more on

developing their retention strategy through incentives like motivation, empowerment, bonus programs,

training and development and so on, all of which may help encourage HCAs to stay in the company.

The findings in this study may contribute to positive social changes by reducing turnover intention

while improving the quality of care and reducing costs of care that affect the lives of the long-term

residents, concerned family members, and significant others.

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1.9 STRUCTURE OF THE RESEARCH THESIS

Chapter one sets out very early on the initial motivations for this work, its significance and currency,

and provides the reader with some contexts to the study. In chapter two, the focus shifts to a review of

existing literature in the study domain. More generally, the chapter delves into a critical evaluation of

prior knowledge on employee’s job satisfaction, turnover and retention in care home companies and

nursing homes in Ireland. More specifically, there the research examines in great detail the factors that

contribute to high employee’s turnover in a couple of healthcare facilities in Ireland and retention strategy

that can be adopted.

A discussion of the research approach and data collection and analysis techniques deployed in this

work is presented in chapter three; justification is given for why the quantitative research method and

close-ended survey questionnaire technique was chosen for the present work.

Analysis of the collected data, the results and findings of this research investigation are all detailed

in Chapter four. Chapter five is the discussion and summary chapter; implications of the overall research

are considered here along with recommendations and suggestions for future studies.

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CHAPTER TWO

LITERATURE REVIEW

2.0 INTRODUCTION

This chapter both explores and articulates relevant gaps in existing knowledge in the problem

domain along with the specific contributions this work makes to fill those voids and advance knowledge.

More generally, academic literature on employee turnover among health care assistants globally and

in Ireland care sector is evaluated. More specifically, the work presented will evaluate main indicators

like: job dissatisfaction, employee compensation, employee engagement, staff-motivation, working

conditions and environment, and so on etc.

2.1 DEFINING THE NURSING HOME CARE

A nursing care home is an institution licensed to provide health assistance to aging and invalid adults

or those members of the society who are terminally ill (Pratt, 2010, Sanford et al, 2015). Senior citizens

with a minimum age of 65 and older are generally covered by this definition.

For a care home often perceived as domiciliary care, this describes a supportive care provided in the

home rather that in a nursing home facility. Like a nursing home, a care home is licensed to provide

health assistance needs by professional caregivers (Drennan, 2018).

Residential care establishments mostly care for individuals who suffer from multiple health issues

(Pélissier et al, 2018). These patients typically require assistance with mobility, supporting nutrition,

personal hygiene and other daily needs. Some of these patients have disabilities, chronic diseases, and

terminal ailments (Freedman and Spillman, 2014). And according to Estabrooks et al (2015), the majority

of persons committed to nursing care home services are often wholly dependent on other people for their

day-to-day lives.

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2.2 JOB SATISFACTION

The issue of job satisfaction and Employee turnover among healthcare assistants globally is an

important problem to talk about. Some of the reasons cited for high turnover includes low compensation,

inadequate benefits, poor working conditions, work life conflict and employee stress (Pouslston 2009,

O’Neill and Davis 2011 and Hinkin and Tracey 2000).

The general health care sector is characterized by high mobility and abnormal working hours as well

as frequent interactions with residents, which require high level care skills from the employees. These

industry characteristics have been cited as part of the reason the industry posts a relatively high rate of

turnover compared to other industries (Mohanty and Mohanty, 2014; Shani, Uriely, Reichel, and

Ginsburg, 2014). The high turnover, low retention and acute shortage of competent employees in the

hospitality sector have significantly impacted the sector (Silva 2006).

The decision of an employee to terminate his/her own contract is usually not a sudden decision

(Rubenstein et al, 2018). Across the globe, the issue of job dissatisfaction and eventual exits among health

care assistants has continued to be a serious issue. In the United Kingdom, HCAs have expressed

dissatisfaction with their jobs; reasons commonly cited are: their pay is not at par with less strenuous

work/workload they have to contend with, limited opportunities for role progression and promotion, and

uncertainties about career growth and development (Spilsbury et al, 2013). A similar study among care

professionals in the UK, pointed to high level of job burnout amongst HCAs working in nursing home, as

reason why so many HCAs eventually become dissatisfied with their jobs (Estabrooks et al., 2015).

Trust is an important construct even in a care home organization. Good communication and

openness positively impact on the development of trust (ibid). Nurses and health care assistants tended to

have a very strong commitment/attachment to their profession. Even so, their commitment and interest

may be rocked by increasing feeling of marginalization by management; if left unchecked, this can

adversely undermine the mutual trust between health care assistants and managers. Not altogether

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surprising, McCabe and Sambroke (2018) found breakdown-in-trust between the nursing assistants and

health care providers to be an important factor contributing to job dissatisfaction.

Friedman and Netze (2020) found that decreased employee engagement negatively affects HCAs;

they also cite and violent actions on CNAs by residents and patients of care homes has led to some HCAs

feeling very dissatisfied with their jobs and in some instances even forced some of them to leave their

posts. Most of the time, the working culture in these care homes often mean that employees are left

feeling like they are unable to freely report/discuss these incidents with management.

Aluttis et al (2014) found that the level of job turnover among CNA’s in Europe is quite high. In an

earlier research, Rosen et al (2011) found that the turnover among nursing assistants in US had more to

do with employee preferences to leverage new opportunities to progress their career outside of a

particular care home establishment rather than on job dissatisfaction per se, or any seeming flaws at their

workplaces. Contrastingly, Chang et al (2017) found that health care workers in the USA were fairly

satisfied with their jobs. Essentially, the overall satisfaction will be from both intrinsic and extrinsic

factors that contributes the wellbeing of employees. However, Bryant (2018) found that when there is

little motivation for care professionals. According to him, demotivation is often a leading contributor to

high staff turnover; they cost the care industry billions of dollars in lost revenues every year.

In Europe, there is a growing elderly population; the projection is that these numbers will gradually

rise from 16% in 2010 to 27% in 2050 (European Commission and Lanzieri, 2011; Leichsenring, 2013).

With this growth in population of the elderly, the demand for care homes will likewise increase. The

challenge therefore is to ensure to that care home companies are recruiting and retaining talented HCAs to

provide quality care to patients (Eenoo et al, 2016)

2.3 EMPLOYEE TURNOVER

The intimate relationships some patients have with their carers foster an atmosphere for emotionally-

oriented care. For patients and residents of care homes, high turnover rates of CNAs are a problem not

- 15 -

least because of the personal relationships and bond some of these patients have with their caregivers

(McQueen, 2012).

Several scholars have made meaningful contributions to the concept of employee turnover.

Employee turnover describes the proportion of employees who leave an organization over a set period

(CIPD, 2014). Armstrong (2012) describes this as a disruptive and costly scenario where staff of an

organization quit working for an organization.

Griffeth and Hom (2001) describe the phenomenon using three lenses: voluntary turnover,

involuntary turnover and dysfunction turnover. According to them, voluntary turnover is initiated by

employees. Involuntary is arranged by the organization as a result of incompetency and inefficiency of an

employee. Dysfunction turnover is detrimental to the organization, as the best employees decide to leave

the organization.

According to Rubenstein et al., (2019), job turnover is a complex occurrence created by multiple

causative factors. Castle and Anderson (2011) link the higher turnover rates of RNs and HCAs in nursing

homes to lower quality of care. Anxiety and work-related stress are other factors contributing to high

employee turnover among HCAs (Kramer & Son, 2016, Perreira et al, 2018, Atkins et al, 2011). Another

contributing factor could be long periods of exhaustion (both physically and psychologically)

(Amponsah-Tawiah, 2014).

A turnover rate of 14% is reported for HCAs working in the health sector, and 19.8% for those

working in the social care sector; reasons cited for why HCAs leave their jobs included inadequate pay

and a lack of appreciation by employers (Cavendish, 2013).

2.4 CAUSATIVE FACTORS OF EMPLOYEE TURNOVER

Employee turnover can be problematic and, in some cases, devastating for organizations. However,

the onus is on the human resources team and management to develop and implement effective evidence-

base guidelines to both mitigate and manage turnover (Allen, Bryant and Vardaman 2010).

- 16 -

Understanding why turnover is a problem in the health care industry is the first step toward being

able to solve it. There are several reasons why employees quit working. According to Branham (2005),

employees tended to leave their employment if: the job no longer matches their ambitions and

expectations, if there are limited or no feedback/coaching tracks within the firm, if there are very few

growth and advancement opportunities, if staff feels unappreciated or unvalued, if staff feels overlabored,

if there is a breakdown- in -trust and confidence between management and staff, and so on. Bryant (2018)

found the following common issue to be poor or a lack of employee-engagement.

To a large extent whether or not an HCA staff derives satisfaction and happiness from his or job may

be determined by the level of the relationship between them and their employers, and the quality of their

day-to-day experiences in the workplace. Perreira et al (2018) found the sort of superior-subordinate

relationship an HCA has in a workplace to be important determinant; from an employee’s perspective,

this is the most important relationship in an organization.

Social opinions about care assistant jobs make the profession appear less attractive; many even

regards it as a low-profile job (Pembroke, 2017). This may be contributing to high turnover among HCAs.

The same study found the lack of work-life balance to be another factor. Due to the nature of their

jobs, HCAs are often made to work irregular shift patterns and nights sometimes for periods up to12

hours. HCAs who work for care home companies typically have to be rotated between different care

homes — going from one client’s home to the other; this can be really stressful and has been heavily cited

as reasons why HCAs quit their roles (Cavendish, 2013, Spilsbury et al., 2013, Estabrooks et al., 2015a,

UNISON, 2016). Moreover, nursing care assistants often have to make long and expensive commute to

the various residential care homes (O'Brien, 2015, Pembroke, 2017).

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2.5 IMPLICATIONS OF EMPLOYEE TURNOVER

Masum et al (2016) noted that turnover and staffing gaps come with a huge cost. While making

efforts for continuity of care, healthcare companies are bedeviled by costs of training potential

replacements as well as overtime payout for agency and travel nurses.

Turnover rates are compounded by job positions that stay unoccupied for a certain period, hence

having an impact on the workplace’s bottom line. Organizations lose valuable knowledge when it suffers

high turnover levels; workloads for the remaining staff may increase in the short-term; staff remaining in

their employment may lose motivation (Taylor, 2019). Reputationally, reoccurring higher levels of staff

turnover may be damaging for care home companies and all stakeholders.

HCA shortages can seriously challenge the efficiency and effectiveness of any health-care delivery

system (Perreira, 2018). Further, an Irish Independent newspaper also revealed that nursing homes

warned they were in a danger of having to close beds due to staffing shortages. The paper cites that if

these staff shortages escalate any further, Accidents and Emergency (A&E) may be in danger of being

overcrowded. This evidence and the high turnover of HCAs reported in literature may be further proof

that the care home and nursing home sector could be facing crises.

2.6 EMPLOYEE ENGAGEMENT

Staff health and wellbeing is a crucially important concern for employers. Leading a healthy life,

both physically and mentally, is a good principle in and of itself, which engaged employers could support.

Healthy employees also benefit the workplace and productivity in many other ways.

As the labor gaps grow, it’s important to identify the areas within the health care industry that are

particularly susceptible to turnover and learn what we can do to slow the rate of turnover. The success of

an organization may be dependent upon its ability to positively engage and retain key employees.

Most would agree that employee turnover has huge cost ramifications (Pilbeam and Corbridge,

2010; Zhang et al, 2014). So essentially, efforts need to be made to curtail these unwanted costs; a crucial

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step towards this is having a good employee engagement and retention strategies. Perreira (2018) makes

the suggestion for employers to do more in terms of their retention strategies to encourage employees to

remain in the organization.

Friedman and Neutze (2020) points to improvement in workplace engagement as key to solving

employee turnover. Discussing some of the many advantage employers stood to gain if they implement

good engagement polices, the authors claim that improved employee engagement may help minimize a

worker’s consideration of other job opportunities, it will help organizations attract top talent in a

competitive employment landscape, and keep current employees happy.

Bryant (2018)’s views are: where employees perceive that their workplaces foster interpersonal

relationships, respect their employees, and empower their employees to be part of the decision-making

processes, they felt less inclined to leave.

Zhang et al. (2014) employed a quantitative design to look at the relationships between employees’

working conditions and intention-to-leave among 1,589 HCAs working across 18 for-profit nursing

homes. Their results indicated that employees’ intentions-to-leave was affected by employees’

perceptions of the workplace. Other studies have found that if HCAs are given regular opportunities to

take part in care planning, they may feel disinclined to leave (Drennan et al, 2018); this gesture may be

seen by them as a sign that they are valued within the organization (ibid).

2.7 EMPLOYEE MOTIVATION

It is difficult to clearly articulate the effects of motivation. However, in the current context,

motivation describes what inspires an employee to perform. A correlation exists between employee’s

motivation, performance, and job satisfaction (Choi and Johantgen, 2012).

- 19 -

It is a generally accepted notion that employees perform better when offered certain privileges; these

employment perks may boost their level of satisfaction with the employment. The phrase: job satisfaction

is defined loosely in this study as “the overall pleasant and positive feeling about one’s job”.

According to Kreitner et al (2002), how well workers respond to their roles at the workplace, the

type of management, and the working conditions and environment, can all affect how satisfied an

employee feels about their job. In Bryant (2018)’s view, trust is as much a strong factor in the healthcare

organization as all the others considered above. Research has also found distrust of management as a

leading cause of high CNA turnover. Mutuality of trust is crucial for motivation (ibid); there needs to be a

healthy trust relationship between health workers and their patients, and between health workers and

management.

Cheloni and tinker (2019) looked at health care professionals working with older people with

dementia (PwD) in the United Kingdom, and found motivation to be an important element for their

professional development, and performance. Using a semi-structured interview technique, their study

found that employees are generally motivated by their previous personal experiences, and what

fulfillment they derived from caregiver-patient relationships. The same study found that employees are

demotivated by organizational factors, working conditions, and environmental factors; it cited poor

leaderships, inadequate staffing levels, lack of development opportunities and many more (ibid).

2.8 WORKING CONDITIONS

Several organizational factors have been linked to high turnover rates. Several studies have indicated that

unfavorable working conditions is a trigger for why employees leave their posts (Kramer, Halfer,

Maguire, & Schmalenberg, 2012; KutneyLee et al., 2013).

HCAs constantly having to work in very stressful working environments are more likely to quit their

roles (Estabrooks et al, 2015a). Separately, Bryant (2018) argues that job-focused stressors are more

likely to lead to higher intentions to leave. In comparing empowered and non-empowered work

- 20 -

environments, another study found that caregivers who felt empowered by their working conditions in

dementia care units experienced more patient-focused stressors (e.g. stress caused by deaths of their

patients), while those working in non-empowered dementia care units experienced more job-focused

stressors (e.g. salaries, workloads, and interpersonal conflicts) (Cheloni and Tinker, 2019).

A number of studies have attributed the higher turnover rates by profit nursing homes to their

organizational policies (McGilton et al., 2014; Woodhead et al., 2014). For instance, the feelings among

CNAs were that these nursing companies prioritized economic gain for their services, rather than the

patients’ clinical outcomes and the care they must receive (ibid). Some nursing homes have more patients

and not enough number of nursing staff to care for them; this can increase the risk for burnout of the

CNAs (ibid).

Micromanagement and excessive workplace surveillance are seen by most employees as

counterproductive. How leaders interact with staff is critical (Jang et al., 2015). If CNAs are made to feel

like they are at the bottom of the tier this can impact on their job satisfaction levels (ibid). According to

Hayes et al. (2012), turnover rates may decrease through effective management, organizational

communication and support processes.

Zhang et al (2013) successfully showed that working conditions could significantly affect the mental

health of CNAs and their intentions to leave. Data from 1,589 employees across 18 for-profit nursing

homes analyzed using Poisson regression modeling indicated that employees who cited at least four

positive features in their workplace were less likely to leave their place of work (ibid). In congruence

with the above, Perreira et al (2018) lists the following features they claim would make nursing

assistances less likely to leave their posts: good interpersonal relationships, respectful environments, and

empowering conditions where employees can contribute to decision-making processes.

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2.9 TWO-FACTOR THEORY

Previous studies have shown the relevance of motivation and job satisfaction to employee retention

in other industries. The motivation-hygiene theory, also called the two-factor theory, initially advanced by

the work of Herzberg, Mausner, and Snyderman (1959), represents the theoretical framework for

understanding the underlying issues that may relate to employee turnover intention among CNAs.

In principle, Herzberg’s two-factor theory articulates constructs that can be manipulated to explain

employees’ perceptions of work environments that could potentially affect motivations addressed in the

theory. The theory addresses motivational constructs that affect job satisfaction; it lists these as:

achievement, recognition, employees' perception, responsibility, advancement, and possibility of growth

(ibid). Additionally, the theory also speaks to the issue of job dissatisfaction; it cites the following factors:

job security, organization commitment, work environment or conditions, working relationships,

supervision, and incentive (ibid).

Most people regard the two-factor theory as useful scaffolding for explaining specific factors that

related to changes in employee turnover (Hitt et al, 2013). It is an important framework for investigating

how factors like: employee compensation, employee engagement, staff-motivation, job satisfaction,

working conditions and environment, and so on, and how these impact on employee turnover (ibid).

2.10 RESEARCH QUESTIONS

Although a host of issues relating to the provision of care for vulnerable elderly groups have been

reported throughout Ireland in both public and private sectors, there is actually very little research-led

information in the problem domain to work with. For some of those studies, emphasis had been on

addressing the issue of staff-motivation, and strategies for reducing burn-out for care workers.

The huge cost of turnover on companies cannot be over emphasized. Employee turnover costs

businesses, including long-term care facilities, over $25 billion on an annual basis (James & Matthew,

2012). Records have it that between 2001 and 2011, turnover rates within the United States increased by

- 22 -

120% per month (Bureau of Labor Statistics, 2012). Records also shows that the turnover rate among

nursing assistants in the long- term care industry was 31% higher compared to other nursing staff in 2012,

resulting in added operational expenses between $22,000 and $63,000 per individual (American Health

Care Association, 2012). The general business problem is that some long-term care facilities have high

turnover rates among its employees that result in costly business expenses and decreases profitability and

productivity. Specific, the business problem noted is that some long-term care facility leaders have

limited information about the relationship between compensation, engagement, job satisfaction,

motivation, and work environment that leads to high CNA turnover (ibid).

That gap in literature is mainly on the Environmental factors that affect care workers. The COVID-

19 global pandemic is grouped under these environmental factors in this research. Furthermore, the legal

factors that contribute to a high employee turnover aren’t addressed emphatically. Another point which

has not been clearly addressed (with suitable remedies) is the assessment of the percentage of HCAs who

work casually, their nationality as well as how strict immigration policies indirectly affect retention of

trained care workers. This research will fill those voids stated above. Primary issues of particular concern

here are those relating to: carer and career satisfaction, general carer well-being, carer skill-set, employee

retention and workplace conditions.

Overall, it could be said that the outbreak of COVID-19 global pandemic has caused panic globally.

The Healthcare assistants and nurses are among the frontline workers who are constantly exposed to

patients with the communicable disease on daily basic (Maben and Bridges, 2020). Psychological stress

could be expected to compound as a result of these healthcare challenges (ibid). In some cases, turnover

equally sets in, especially when these healthcare workers feel their wages do not worth the risk. As

turnover reoccurs, job productivity and delivery of quality care could be expected suffer a setback

(Perreira, 2018).

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This research is guided by the following research questions:

1. Is there any evidence that African nationals make up a larger proportion of HCA

temporary staff working in Dublin?

2. What are the differences in perceptions towards COVID-19 pandemic between male and

female Healthcare assistants in Ireland?

3. To what extent does staff-motivation overall influence job satisfaction among HCAs?

4. To what extent is decline in HCAs’ job productivity correlated with work-related stress?

5. Does high staff turnover leave any detrimental effect on existing staff and the workplace?

6. What is the relationship amongst salary and benefits, work-life balance and favorable workload

on job satisfaction between male and female HCAs working in Ireland?

To address these questions, the quantitative approach would be the most effective and therefore be

adopted to gain insight appropriately. Data will be collected from a selected population of a group of

healthcare assistants, on the assessment of job satisfaction and employee turnover among healthcare

assistants in Dublin at large, using questionnaires. Before the survey proceeds, contact to relay the intent

to undertake research will be made physically to the care-home companies and nursing homes.

In conclusion, the questionnaire will evaluate the factors that affect care-workers intentions to either

stay or to leave their current workplace; with possible recommendations. Further details of the research

approach will be explained more in the methodology section.

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CHAPTER THREE

METHODOLOGY

3.0 INTRODUCTION

This chapter discusses the methodological framework to be used for this research study. The

research approach and study design are articulated. The researcher introduces the population of interest

here including what the sample size for this study will be and the sampling techniques it will utilize. A

discussion on the data collection techniques to be used is presented. Additionally, this chapter gives a

brief mention of what data analysis approaches and tools this work will adopt.

3.1 METHODOLOGICAL APPROACH

Methodological approach according to Hopkins (2008), concerns the courses of action used by the

researcher to carry out investigations on research problems, and in most cases determine the relationship

between two factors in order to satisfy the main objectives of the study.

There are mainly three approaches to be taken when carrying out a research methodology these are:

qualitative, quantitative and the mixed method (Saunders, Lewis and Thornhill, 2009; Norris et al, 2015).

All three data collection approaches differ significantly. For instance, Horn (2009) stresses that as a

research procedure, utilizing statistical data and manipulations, quantitative research approach can be

applied to explain a social phenomenon. Saunders et al (2012) also contribute that quantitative is

normally used as a synonym for any data collection technique that involves the use of survey-type

questionnaires. Choy (2014) explains that the qualitative research approach is best suited for explaining

social phenomenon; it relies on in-depth information about human behavior often collected through non-

numerical data such as interviews, analysis of images, video clips (ibid).

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Furthermore, Cooper et al, (2014) posits that qualitative research methodology aims mainly at

addressing questions about why and how people behave in a certain way; they say this form of research is

useful if the aim is to gain an understanding of underlying opinions, motivations and reasons for those

behaviors. To a large degree, qualitative research is used by researchers when their target is to uncover

new or further insights on a phenomenon (ibid). Lastly, Schindler and Cooper (2014) explain that

quantitative and qualitative techniques could both be used in research design as mixed research approach.

To make clear, to gain a deeper insight into the problem of high employee turnover among formal

caregivers (carers), the present study proposes to adopt the quantitative research approach with survey-

type questionnaires as its primary data collection technique.

3.2 RESEARCH APPROACH

A cross-sectional survey using self-administered questionnaire was conducted to assess the factors

influencing job satisfaction among health care Assistants. The questionnaire is most widely used

procedure for data collection as they are standardized, consent is required and anonymity is provided,

reliving the respondent to leave the research at any point of time (Saunders et al., 2009). As the delivery

and collection method is through a direct contact with potential respondents, it will enhance the

probability of getting back the responses in larger proportions and reducing the time lapse and effort

involved in collection and distribution of questionnaires; as documented by Gray (2009) that it is time.

According to Denscombe (2014), it is a simple direct technique to extract opinions from varied numbers

of people and the forte of using questionnaire is generation of worthwhile ideas and results if they are

administered properly.

3.3 MEASURING INSTRUMENT

Data on the assessment of employee turnover among healthcare assistants (HCAs) in Dublin, Ireland

will be collected using primary data (survey questionnaire) and secondary data (existing literature).

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According to Winter (2000), survey questionnaires can take two forms; these are: close-ended questions

or open-ended questions. The type of information a researcher wishes to solicit from respondents can

generally help determine which one of these two forms of questions is deployed as data collection

technique.

Close-ended questions may be used to gather determinable and objective data, and are used in

quantitative research. By design, a close-ended question asks a respondent to select an answer from a list

of alternatives. Also referred to as free-response question, with an open-ended question the respondent is

not offered a choice of answers; instead it lets respondents verbalize the answer in their own terms. Open-

ended questions are in fact subjective in nature; they do not involve numbers necessarily; they may be

used to gather data about behaviors, preferences and facts. Additionally, compared to close-ended

questions, results from open-ended questions are also more difficult to analyze. A huge benefit of the

close-ended questions in survey is that the scope to limit a participant’s input into the phrasing of

responses is significantly enhanced. Traditionally, for respondents’ multiple-choice questions are also

easier to answer. Compared to open-ended survey questions, a generally accepted opinion is that

questions in multiple-choice survey are substantially better structured towards the goals of a research.

For the present work, close-ended survey questions will be used; the questionnaire will be measured

on a five-point Likert scale, consisting of options: strongly disagree, neutral, agree, and strongly agree. To

measure the respondents’ opinion regarding employee turnover of CNAs in Dublin; except where a

positively worded question had to be reversed coded, most of questions in the survey instruments are

coded such that strongly disagree = 1 and strongly agree = 5. To a large extent, it usually gives helps to

gain deeper insight from the respondents.

3.4 VALIDITY AND RELIABILITY OF THE MEASURING INSTRUMENT

Saunders et al (2009), has explained that validity and reliability tests of a questionnaire ensures it

measures exactly what the researcher sets it out to do; these tests can help determine that the instrument is

- 27 -

able to produce stable, consistent results and findings if used in a different kind of setup (ibid). With

validity tests more specifically, the focus is on whether or not the findings are really about what they

appear to be about (ibid). To measure the reliability and validity of the questionnaire on staff turnover, a

pilot test will be used. It was developed based on (Das and Baruah 2013) findings of similar research.

3.5 STUDY SITE

This study is performed across five care home companies and three private nursing homes. The

study sites are situated in the north of Dublin city, between 8 -12 kilometers of Dublin city Centre and

around the areas of Drumcondra, Santry, Phibsborough, Beumont, Swords, Malahide and Finglas.

For research ethics reasons, the names of these care and nursing homes, and the identities of their

staff will remain anonymous.

3.6 POPULATION

For this study, the targeted population will be drawn from healthcare assistants (HCAs) working full

time or part time for care home companies; the other requirement is that participants would have also

been deployed there for a minimum duration of one year.

3.7 SAMPLE SIZE

Across Dublin, there’s evidence to suggest that on the average, most care home companies have 35

or more HCAs working for them. These care homes have full time, part-time, and agency staff working

for them, most of whom are student nurses. For this research project, the study group as already noted are

healthcare assistants (HCAs) working on permanent or contractual basis in north Dublin; the sample size

is drawn from three private nursing homes and care home companies.

All the chosen companies are run as a group of companies owning at least 3–5 homes in different

parts of Ireland and each having a capacity of 201–300 employees. Data would be collected from several

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nursing and care homes. To be exact, one care home company in fact has 47 HCAs; the other two have 53

and 41 HCAs respectively. The projected sample size for this study was about 75 HCAs drawn from care

companies in Dublin, Ireland.

3.8 DATA COLLECTION

Initial contact to relay the intent to undertake research will be made physically to the care home

companies and nursing homes. Once initial permission has been agreed and approved by their

management, participant consent forms will be hand-delivered to care worker staff in those companies to

complete. The researcher may even consider visiting the proposed participants to explain the parameters

of the research.

All the responses recorded for the survey will be anonymous; this will give an added level of privacy

and confidence in the data collected. Participants will be required to complete the questionnaire online

administered via the google forms tool. It is cost effective, and can cover a wider population in a short

time. Once signed up on the program, participants will have up to 7 days to complete the questionnaire.

The questionnaire will assess the factors that affect care-workers’ decision to stay or leave an

employment; it will assess what possible recommendations that could be made to an employer to increase

staff retention. The questionnaire has 6 biographical data questions, and 18 questions around HCA

employee job satisfaction, staff turnover and retention.

3.9 DATA ANALYSIS

For quantitative data analysis, Horn (2009) proposes the use of software products like Survey

Monkey, SPSS, SNAP, Excel, Access, Google Forms, etc. To this end, this work will utilize the Google

forms for Data collection. The Google Forms software allows one to both create and administer

questionnaires online. The tool has been chosen for convenience; it is also cheaper to administer and it

environmentally friendly as this would mean that no paper copies of this questionnaire would be

- 29 -

administered to study participants. A quantitative data analysis using SPSS software would be performed

on data collected from the close-ended (multiple-choice) questionnaire.

3.10 CONCLUSION

This chapter looked at the different research methodologies and methods, and reviewed the

suitability of each one for the present study. A few nursing homes and a few care companies would be

consulted to carry out the survey. The use of an online questionnaire-type survey has been chosen as the

main data collection technique for this research investigation considering how suitable it is to gain deeper

insights from the direct target population for this research.

Here the researcher has set out the study sites, the study population and the sample size for this

work. An explanation is given for how the researcher seeks to lobby both management and HCAs in

select care companies in Dublin, Ireland to participate in this research program. All of the scales involved

Likert-type answer formats. The points along a rating scale may not represent equal intervals; however,

rating scale data are closer to interval than ordinal scale data, and researchers may use rating scale data as

interval data in statistical analyses (Meyers, Gamst, & Guarino, 2013).

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CHAPTER FOUR

RESULTS AND ANALYSIS

4.0 INTRODUCTION

Starting with a brief description about how data for the study was collected and prepared for

analysis, this chapter presents the results of the descriptive statistics (univariant and bivariant analysis),

and the inferential statistics used as a basis in the study to make predictions about whether or not the

results produced by his research are significant. This chapter concludes with a summary of the findings of

this research project.

4.1 RESEARCH QUESTION

To recap, this research is guided by the following questions:

1. Is there any evidence that African nationals make up a larger proportion of HCA

temporary staff working in Dublin?

2. What are the differences in perceptions towards COVID-19 pandemic between male and

female Healthcare assistants in Dublin?

3. To what extent does staff-motivation overall influence job satisfaction among HCAs?

4. To what extent is decline in HCAs’ job productivity correlated with work-related stress?

5. Does high staff turnover leave any detrimental effect on existing staff and the workplace?

6. What is the relationship amongst salary and benefits, work-life balance and favorable workload

on job satisfaction between male and female HCAs working in Ireland?

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4.2 DATA PREPARATION AND ANALYSIS

A discussion of how the questionnaire data for this research was collected, collated, and analyzed is

next presented. As previously discussed in the methodology chapter, primary data was collected via

questionnaire survey method which was administered online via google forms. A total of 66 HCA

respondents completed the survey out of the projected 75 participants. Using google forms automatically

exports the responses in an excel spreadsheet. For this analysis, the first step was to color-code questions

that were investigating same variable.

The questions were independently coded (E.g. the gender question, 1 = Male, 2 = Female). Next, the

coded data was transferred to the SPSS statistical package – this is the software tool that was used for the

entire analysis. Here each variable being measured and corresponding to a specific questionnaire item was

given a specific variable and a label. Each respondent was given a unique ID (201, 202, 203… to 266).

Once all of the data have been entered into SPSS, where necessary, all of the positively worded questions

(which by the way are fewer in number) were reversed coded so that they aligned with the other

negatively worded questions.

4.3 RESULTS | BIO-DATA

N %

Employment length 0 – 11 months 21 31.8

1 – 2 years 24 36.4

2 – 3 years 10 15.2

3 years or more 11 16.7

Care company type HomeCare 41 62.1

Nursing Home 25 37.9

Table 1: Other socio-demographic bio-data

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Presented in Table 1 is the descriptive statistics to two specific socio-demographic information (bio-

data) captured by the bio-data. Q4 asks participants to indicate the type of care company they are

currently working for, while Q6 asks respondents to indicate how long they have been in that

employment. The result shows that there are almost twice as many respondents working for HomeCare

(62%) and there are for Nursing Home (37%). The results on employment length indicate that the

majority of the respondents have been in the job for just under 2 years (approximately 31% for 0 – 11

months, and 36% for 1 – 2 years). Only 16.7% have been in the job for 3 years or more. Visual

representations of both of these datasets are shown in Figures 1A and 1B.

Figure 1A showing care company type

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Figure 1B showing employment length

An ordinal question type (Q1) in the survey instrument asked respondents to indicate their age range.

The results are presented in Table 2 and Figure 2. Another questionnaire item (Q2) of a nominal type,

asks respondents to indicate their gender; the results is presented in Table 3; correspondingly a visual

charting of this result is shown using bar chart in Figure 3. A crosstabulation of age range and gender is

presented in Table 4 and charted in Figure 4.

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Age Range

Frequency Percent Valid Percent

Cumulative

Percent

Valid 18-26 28 42.4 42.4 42.4

27-35 29 43.9 43.9 86.4

36-44 5 7.6 7.6 93.9

45-53 2 3.0 3.0 97.0

54-62 2 3.0 3.0 100.0

Total 66 100.0 100.0

Table 2: Frequency distribution of respondents’ age range

Figure 2: A pie chart of respondents’ age

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Gender Group

Frequency Percent Valid Percent

Cumulative

Percent

Valid Male 40 60.6 60.6 60.6

Female 26 39.4 39.4 100.0

Total 66 100.0 100.0

Table 3: Frequency distribution of respondents’ gender group

Figure 3: A bar chart representation of respondents’ gender group

- 36 -

Age Range * Gender Group Crosstabulation

Count

Gender Group

Total Male Female

18-26 18 10 28

27-35 18 11 29

36-44 2 3 5

45-53 1 1 2

54-62 1 1 2

Total 40 26 66

Table 4: Crosstabulation of age range and gender

Figure 4: A stacked bar chart of age range and gender

- 37 -

Research question (RQ1) is answered by analysing questionnaire item 3 and questionnaire item 6;

the two are category type questions; they ask respondents to indicate their nationality and the nature of

their job respectively. For Q6, respondents can choose from a permanent or casual job type. And for Q3

respondents can make their selection from either African, Irish, Other EU, and Other (see full

questionnaire in the appendix section of this dissertation). A crosstabulation matrix mapping the

nationality type against the nature of job is presented in Table 5. This result is represented using a cluster

bar chart shown in Figure 5.

To analyse the differences or relationships between Nationality type and Job type, a two-way chi-

square test was performed on both of these nominal datasets (see results in Table 6). A Pearson chi-square

test showed there was no statistical significant association between nationality type and job type, X(3) =

3.198, p = .362.

Crosstabulation

Count

Nature of job

Total Permanent Casual

Nationality Type African 9 19 28

Irish 6 5 11

Other EU 6 4 10

Other 8 9 17

Total 29 37 66

Table 5: Crosstabulation of nationality and job type

- 38 -

Figure 5: Job type mapped against nationality

Chi-Square Tests

Value Df

Asymptotic

Significance (2-

sided)

Pearson Chi-Square 3.1983a 3 .362

Likelihood Ratio 3.232 3 .357

Linear-by-Linear Association 1.395 1 .238

N of Valid Cases 66

a. 2 cells (25.0%) have expected count less than 5. The minimum expected

count is 4.39.

Table 6: Two-way Pearson chi-square test

Research question (RQ5) (Does high staff turnover leave any detrimental effect on existing staff and

the workplace?) is answered by Q7, Q8 and Q9 in the questionnaire survey instrument.

- 39 -

Figure 6: Questionnaire Item 7 (Q7)

Figure 7: Questionnaire Item 8 (Q8)

- 40 -

Figure 8: Questionnaire Item 9 (Q9)

To determine the relationships between the variables measured in Q7, Q8 and Q9, for the analysis,

all three questions are measured at the ordinal level. A Kendall’s tau_b was conducted to determine the

relationships between the variables measured amongst 66 respondents. There was a strong positive

correlation between Q6 and Q7, this was not statistically significant (Tb = .166, p = .122, n = 66). There

was a strong positive correlation between Q7 and Q8, this was not statistically significant (Tb = .416, p =

.000, n = 66). There was a strong positive correlation between Q6 and Q8, this was not statistically

significant (Tb = .236, p = .028, n = 66).

- 41 -

Table 7: Kendall’s tau b correlation coefficient for Q7, Q8 and Q9

To answer RQ3, the descriptive statistics for questionnaire item Q13 (My level of job satisfaction is

low) and Q15 (My level of motivation with this job is high) is presented below in Table 8 and Table 9. A

Spearman’s rank-order was run to determine the relationship between Q13 and Q15. There was a strong

positive correlation between job satisfaction and job motivation, which was not statistically significant

(rs(64) = .425, p = .000).

My level of Job satisfaction is low

Frequency Percent Valid Percent

Cumulative

Percent

Valid Strongly Disagree 8 12.1 12.1 12.1

Disagree 20 30.3 30.3 42.4

Neutral 17 25.8 25.8 68.2

Agree 16 24.2 24.2 92.4

Strong Agree 5 7.6 7.6 100.0

Total 66 100.0 100.0

Table 8: Questionnaire item 13 indicating level of job satisfaction

- 42 -

Job_MotivationRC

Frequency Percent Valid Percent

Cumulative

Percent

Valid Strongly Agree 12 18.2 18.2 18.2

Agree 32 48.5 48.5 66.7

Neutral 10 15.2 15.2 81.8

Disagree 10 15.2 15.2 97.0

Strongly Disagree 2 3.0 3.0 100.0

Total 66 100.0 100.0

Table 9: Questionnaire item 15 indicating level of job motivation

Correlations

My level of Job

satisfaction is

low

Job_MotivationR

C

Spearman's rho My level of Job satisfaction is

low

Correlation Coefficient 1.000 .425**

Sig. (2-tailed) . .000

N 66 66

Job_MotivationRC Correlation Coefficient .425** 1.000

Sig. (2-tailed) .000 .

N 66 66

**. Correlation is significant at the 0.01 level (2-tailed).

Table 10: Spearman’s rho correlation between job satisfaction and job motivation

Research question (RQ4) is answered by analysing questionnaire item 8 (When an employee has left,

it affected my productivity) and questionnaire item 11 (I find my job to be very stressful). The descriptive

statistics for both this data is represented using cluster bar in Figure 9. A Kendall Tau_b correlation test

was run to determine the relationships between productivity (Q8) and work-related stress (Q11). There

- 43 -

was a strong positive correlation between productivity and work-related stress which is not statistically

significant (Tb = .041, p = .690, n = 66).

Figure 9: Productivity and work-related stress

Correlations

I find my job to be

very stressful

When an

employee has left,

it affected my

productivity

Kendall's tau_b I find my job to be very

stressful

Correlation Coefficient 1.000 .041

Sig. (2-tailed) . .690

N 66 66

When an employee has left, it

affected my productivity

Correlation Coefficient .041 1.000

Sig. (2-tailed) .690 .

N 66 66

Table 11: Kendall’s correlation between productivity and work-related stress

- 44 -

Research question RQ2 is answered by analyzing questionnaire item 2 (Gender) and questionnaire

item 12 (My job has gotten my job has gotten more stress amidst COVID-19). There is a significance

difference in the two means: gender (1.39) and COVID-19 related stress (4.08) — see Table 12. A rank-

biserial correlation was run to determine the relationship between COVID-19 pandemic related stress and

gender. There was a negative correlation between COVID-19 pandemic related stress and gender, which

was not statistically significant (rs = -.127, n = 66, p = .311).

Statistics

Gender Group

My job has gotten

more stressful

amidst the

COVID-19

pandemic

N Valid 66 66

Missing 0 0

Mean 1.39 4.08

Median 1.00 4.00

Skewness .444 -.961

Std. Error of Skewness .295 .295

Kurtosis -1.860 .023

Std. Error of Kurtosis .582 .582

Table 12: Descriptive statistics for gender and covid-19 work-related stress

- 45 -

Figure 10: Visual representation for gender and covid-19 work-related stress

Correlations

My job has

gotten more

stressful amidst

the COVID-19

pandemic Gender Group

Spearman's rho My job has gotten more

stressful amidst the COVID-

19 pandemic

Correlation Coefficient 1.000 -.127

Sig. (2-tailed) . .311

N 66 66

Gender Group Correlation Coefficient -.127 1.000

Sig. (2-tailed) .311 .

N 66 66

Table 13: Spearman’s rho correlation test between gender and COVID-19 work-related stress

- 46 -

Research question RQ6 is answered by analyzing questionnaire items 20 (Good pay), 21 (Favorable

workload) and 22 (Work-life balance) and questionnaire item 2 (Gender). As highlighted in the literature

review, questionnaire items 20, 21 and 22 are considered to be some of the core factors that would

influence the career decision/choice and therefore job satisfaction of a healthcare assistant.

Using gender as the grouping variable (of independent variable) and, good pay, favorable work-load,

and work-life balance as the dependent variables, a Kruskal-Wallis H test was run to measure the

association between all three dependent variables on gender. Tables 14 and 15 present their descriptive

statistics and mean ranks respectively.

A Kruskal-Wallis H test (Table 16) shows that there was no statistically significant difference for

good pay, favorable workload and work-life balance between the gender groups. X2 (1) = 1.371, p = .242,

with a mean rank good pay of 35.67 for male, and 30.15 for female; X2 (1) = .178, p = .673, with a mean

rank favorable workload of 34.28 for male and 32.31 for female; X2 (1) = .230, p = .631, with a mean

rank work-life balance of 32.61 for male and 34.87 for female.

Descriptive Statistics

N Mean Std. Deviation Minimum Maximum

Good pay 66 2.18 1.391 0 5

Favorable workload 66 1.86 1.276 0 5

Good work-life balance 66 1.88 1.365 0 5

Gender Group 66 1.39 .492 1 2

Table 14: Mean and standard deviation for Q20, Q21 and Q22

- 47 -

Ranks

Gender Group N Mean Rank

Good pay Male 40 35.67

Female 26 30.15

Total 66

Favorable workload Male 40 34.28

Female 26 32.31

Total 66

Good work-life balance Male 40 32.61

Female 26 34.87

Total 66

Table 15: Mean ranks of Q20, Q21 and Q22

Test Statisticsa,b

Good pay

Favorable

workload

Good work-life

balance

Kruskal-Wallis H 1.371 .178 .230

Df 1 1 1

Asymp. Sig. .242 .673 .631

a. Kruskal Wallis Test

b. Grouping Variable: Gender Group

Table 16: Kruskal-Wallis H test statistics for Q20, Q21 and Q22

- 48 -

4.4 AD-HOC ANALYSIS

The focus in chapter 4 was to present the results of the statistical analysis, that were performed in

lieu of the research questions for this dissertation. For research question RQ1, initial assumptions both

from the literature review and the researcher’s personal experience was that non-Irish, specifically people

of African descent, most of whom are students, make more than 50% of the work-force for healthcare

assistants in Dublin. The researcher was interested in putting these initial theories/assumptions to test.

Even though there was no statistically significant association between nationality type and job type in the

result posted, a quick look at the descriptive statistics itself reveals that the number of Irish nationals

(permanent 6; casual 5) currently working as HCAs were substantially fewer than the number of Africans

(permanent 9; casual 19). More so, Africans working as casual (temporary) staff make up the majority of

those numbers. More specifically, the results published here show that out of the 66 respondents who

completed the survey, African and non-EU nationals represents the largest percentage of the total

population of HCAs in Dublin.

For research question RQ2, more than assessing the differences in perceptions towards COVID-19

pandemic between male and female Healthcare assistants in Ireland, it is interesting to note that a visual

analysis of the clustered bar chart in Figure 10 reveals that more HCA staff rated strongly that their job

has become more stressful with the outbreak of the COVID-19 global pandemic.

Research question RQ3 assesses the extent to which staff-motivation influences job satisfaction

among HCAs. Research question RQ4 assesses the correlation between the decline in HCAs job

productivity and work-related stress. According to Bryant (2018), work-related stressors are more likely

to lead to higher intentions to leave. With job positions staying unoccupied for long periods of time as a

result of increasing turnover rates as documented in the literature review, and with workloads for the

remaining staff possibly increasing in the short-term, it stands to reason that this situation would more

than likely, increase the stress levels for HCAs. These arguments are supported by the statistical results

- 49 -

posted in this chapter. In fact, for staff remaining in their employment, Taylor (2019) argues they may

lose motivation.

A correlation exists between employee’s motivation, performance, and job satisfaction (Choi and

Johantgen, 2012). Also, in the literature review, improvement in workplace engagement was identified as

key to solving employee turnover (Friedman and Neutze, 2020). In a bid to further understand what could

motivate healthcare assistants to remain in their roles, research question RQ6 assessed the relationships

amongst favorable wages, favorable work-load, and good work-life balance on job satisfaction. Although

not statistically significant, there is evidence as the statistical result published show, a strong positive

relationship exists between these variables.

- 50 -

CHAPTER FIVE

DISCUSSION AND CONCLUSION

5.0 DISCUSSION AND SUMMARY

Basically, existing literature evaluated indicated that the respondents have concerns about their

individual workload. When asked about their working conditions of when an employee leaves, 39.4% of

the 66 respondents agreed strongly that their workload increases when employees leave; 48.5% out of the

66 respondents agreed and stressed on the same issue. In essence, the greater percentage agreed that

turnover increases their workload with a total percentage of 87.9.

When asked about their productivity when an employee leaves, 10.6% strongly agreed that their

productivity is affected when an employee exits. 33.3% agreed that their productivity is affected when an

employee exits. 27.3% were uncertain, 21.2% disagreed, while 7.6% strongly disagreed indicating that

their productivity is not affected when an employee exits. Out of the 66 respondents, a total of 43.9%

agreed fairly or strongly that turnover affects their productivity, while a total of 28.8% disagreed fairly or

strongly, indicating that their productivity is not affected when an employee exits. However, the

responses of the majority therefore show that, to some extent, turnover affects the productivity of the

remaining employees.

When asked about their morale when an employee leaves, 13.6% strongly agreed that their morale is

affected when an employee exits. 33.3% agreed that their morale is affected when an employee leaves

their workplace. 25.8% were uncertain, 18.2% disagreed, while 9.1% strongly disagreed indicating that

their morale is not affected when an employee exits. However, out of the 66 respondents, a total of 46.9%

agreed fairly or strongly that turnover affects their morale and motivation, while a total of 27.3%

disagreed fairly or strongly, indicating that their morale and motivation is not affected when an employee

- 51 -

exits. However, the responses of the majority therefore show that, to some extent, turnover affects the

morale of the remaining employees.

When asked about stress when an employee leaves, 12.1% of the respondents strongly agreed that

they find their job to be very stressful. 37.9% of the respondents agreed that they find their job to be very

stressful. 13.6% of the respondents were uncertain, 33.3% of the respondents disagreed, while only 3%

of the respondents strongly disagreed indicating that they do not find their job to be very stressful.

However, out of the 66 respondents, a total of 50% agreed either fairly or strongly that turnover affects

their morale and motivation, while a total of 36.3% disagreed either fairly or strongly, indicating that they

do not find their job to be very stressful. However, the responses of the majority therefore show that, to

some extent, stress is an issue for HCAs working in Dublin.

When asked about COVID-19 workload related stress, 39.4% of the respondents strongly agreed

that their workload has increased amidst the outbreak of COVID-19. 40.9% of the respondents agreed

that their workload has increased amidst the outbreak of COVID-19. 7.6% of the respondents were

uncertain, 12.1% of the respondents disagreed, indicating that their workload has not increased amidst

COVID-19, while none of the respondents strongly disagreed. However, out of the 66 respondents, a

huge total of 80.3% agreed either fairly or strongly that their workload has increased amidst the outbreak

of COVID-19, while a total of 12.1% disagreed either fairly or strongly, indicating that the outbreak of

COVID-19 has not caused an increase in their workload. However, the responses of the majority therefore

show that, to a large extent, their workload has increased amidst the outbreak of COVID-19.

When asked about workload concerns, 6.1% of the respondents strongly agreed that they are

concerned by the sheer size of their workload. 57.6% of the respondents agreed that they are concerned

by the sheer size of their workload. 13.6% of the respondents were uncertain, 21.2% of the respondents

disagreed, while only 1.5% of the respondents strongly disagreed indicating that they are not concerned

by the sheer size of their workload. However, out of the 66 respondents, a total of 69.1% agreed either

fairly or strongly that they are concerned by the sheer size of their workload, while a total of 22.7%

- 52 -

disagreed either fairly or strongly, indicating that they are not concerned by the sheer size of their

workload. However, the responses of the majority therefore show that, to a large extent that HCAs in

Dublin are concerned by the sheer size of their workload.

When asked about level of motivation, 18.2% of the respondents strongly agreed that the level of

motivation with their job is high. 48.5% of the respondents agreed that the level of motivation with their

job is high. 15.2% of the respondents were uncertain, 15.2% of the respondents disagreed, while only 3%

of the respondents strongly disagreed indicating that the level of motivation with their job is high.

However, out of the 66 respondents, a total of 66.7% agreed either fairly or strongly that the level of

motivation with their job is high, while a total of 18.2% disagreed either fairly or strongly, indicating that

the level of motivation with their job is high.

When asked about work-life balance, 18.2% of the respondents strongly agreed that their work-life

balance has been quite poor. 39.4% of the respondents agreed that their work-life balance has been quite

poor. 18.2% of the respondents were uncertain, 24.2% of the respondents disagreed, indicating that their

work-life balance has not been quite poor, while none of the respondents strongly disagreed. However,

out of the 66 respondents, a huge total of 61.2% agreed either fairly or strongly that their work-life

balance is quite poor, while a total of 24.2% disagreed either fairly or strongly, indicating that their work-

life balance has not quite poor. However, the responses of the majority therefore show that, to a large

extent, their work-life balance has quite poor.

Finally, when asked about employer-employee engagement, 6.1% of the respondents strongly agreed

that there is a very low management engagement with their work. 36.4% of the respondents agreed that

there is a very low management engagement with their work. 17.6% of the respondents were uncertain,

37.9% of the respondents disagreed, while only 3% of the respondents strongly disagreed indicating that

there is a very strong management engagement with their work. However, out of the 66 respondents, a

total of 42.5% agreed either fairly or strongly that there is a very little management engagement with their

- 53 -

work, while a total of 40.9% disagreed either fairly or strongly, indicating that there is a strong

management engagement with their work.

However, on the question about factors that could promote retention, the entire respondents have

varying views, indicating that good pay and other factors may not be enough to keep Healthcare assistants

who are bent of exiting.

5.1 RECOMMENDATIONS

In this study Healthcare assistants showed a concern for their workload. There is a need for

influencing support among healthcare team workers (Eenoo et al, 2016; Maben and Bridges, 2020). It

recommended that the management other senior and experienced care workers at the helm, has a task of

initiating a better team support, and always find a way to make the other junior care workers feel safe,

valued and welcomed as quickly as possible (ibid). additionally, a deeper managerial support should be

provided, as well as the provision of adequate psychological or other possible support (Perreira, 2018).

Another point noted is that of productivity. A significant percentage of the respondents admitted that

employee exit affects their productivity. Therefore, the researcher recommends the need for educating and

training of care workers, as well as the adjustments on their work structures which could improve their

productivity. There is a strong possibility of an improvement on their productivity and quality of care

when these are considered (Shannon and McKenzie-Green, 2016). As Garavan et al (2012) suggested,

training and development talents represents an important component of the overall management of

employees.

Another point stressed is stress and job satisfaction. The researcher also recommend that efforts

should be made by the management recruit more but enough staff for the work required as this will reduce

overburdened workload. Reducing of workload will mend a lot of surfacing problems such as work stress,

work pressure, job dissatisfaction, low morale/boredom to work and burnout (Shannon and McKenzie-

Green, 2016; Perreira, 2018). While improving retention, efforts need to be made on retaining trained

- 54 -

employees who have shown enthusiasm towards their job tasks regardless of their nationality. The survey

shows that a greater percentage of care workers working in Dublin are neither Irish citizens nor EU

citizens (mainly of African descent). The survey further shows that the greater percentage of the care

workers work causally. As there is an unending increase in the demand of care-workers, the researcher

recommends that immigration policies could be reversed in a way to accommodate the care workers of

other nationalities (particularly the ones who need visas to remain in Ireland), who might have shown

utmost enthusiasm and intentions of remaining in the care-sector for a longer term.

As employer-employee engagement is noted, the researcher recommends that proper

communications through group meetings as well as coming up with team building sessions where

employees and their management meet up to discuss about the work matters and bring suggestions on

how they could be addressed. The researcher also recommends that every care company should have

suggestion boxes or online platforms where employees can state possible grievances which management

make follow up on every month end and reassurances the care workers that their grievances or

suggestions are taken into consideration.

An idea of coming up with proper exit interviews would count if being carried out appropriately

Spain and Groysberg (2016) note that exit interviews would aid in getting to know about the thoughts of

the current employers and this would give an insight into where the major problem lies. They further note

that in other to take this approach, organizations should aim at following certain steps: Discover relevant

HR issues and Figure out the view of employees about the work

Another point of interest is the unfavorable working conditions. Consideration must be given to the

workers as regards to working hours. As Pilbeam and Corbridge (2006) immensely contribute, this can be

achieved by scheduling flexible working time and sharing jobs appropriately among the part-time and

full-time staffs, in order to keep them operating at maximum capacity without wearing them out. The

CIPD (2005b) immensely contributes that that flexible working can play a vital role and for health and

- 55 -

safety reasons as well. Taylor (2014) cited in “Irish times” that flexible working aid employees to attain

an exceptional Work-Life Balance when blending their job with other responsibilities.

Just as Pace and Kisamore (2017) gave suggestions on how exit interviews can boost employee

retention, A right approach to be taken in the conducting of exit interviews is by ensuring that the said

employees are given voice to enable them give clear details about their experiences, express their

concerns and dish out their suggestions.

5.2 CHALLENGES AND LIMITATIONS OF THE STUDY

There are about 450 nursing home in Ireland and about 13000 private providers operating in Ireland

(nursing home Ireland, 2019; Analysis of Irish Home Care Market, (2019)). however as much as there

were so many care companies that could have been part of the study only four care companies approved

the conduct of the survey, as the researcher had worked there which made it a bit easier. Also, the initial

target of the survey was to target about 150 Healthcare assistants and about 10 care companies. However,

the lockdown rule, made by the Irish government due to COVID-19 made it very difficult to gain proper

access to conduct the survey. Also, that HSE (Health Service Executive) and Nursing home Ireland (NHI)

issued guidance to its members and to the public regarding visitors’ restrictions which is necessary to

safeguard the well-being of Residents in the nursing home care due to COVID-19. This fact made it very

difficult to achieve the initial targeted number of respondents. Even though only four care companies

(nursing home facilities and homecare companies) were used for conducting the research, the researcher

feels that the data obtained accurately reflected the opinions, situations and mindset as it is in the Ireland

nursing home industry.

The researcher was also faced with a challenge of missing important files that could help further in a

successful completion of this research. Other technical issues face by the researcher are not excluded.

- 56 -

5.3 SCOPE FOR FURTHER STUDIES

It is worthy of note that this finding of this study should not be generalizable as further investigation

into the subject is necessary. It would be interesting to investigate further, factors that could impede

productivity and delivery of quality care; factors that would prevent employee exit. Moreover, the

researcher found that sampling technique can play a vital role when investigating job satisfaction,

motivation and turnover, as findings concluded in this study are subjective perceptions of the respondents

based on their self-assessment that may be biased due to lack of knowledge or external pressure. The

present study results are supported by literature which is a positive indication and extinguisher for further

research in some organizational or contextual settings.

As this study was done only in a few care companies, it would be interesting to do a further research

of same, but this time looking into healthcare assistants working in private and public hospitals. It would

also look at healthcare assistants in the whole of Ireland rather than focusing only in Dublin.

5.4 ETHICAL CONSIDERATIONS

This study has put in place all measures possible to reduce amount of harm and risk to the

participants by promoting ethical behavior throughout the research process and activities. Roberts et al

(2019) notes observing ethics is an important procedure meant to protect the participants. First and

foremost, the researcher attained the ethical clearance from the college to go ahead with their research and

for confidentiality assurances of the participants. Secondly, for further certainty and protection of the

respondents, the researcher went to the population sites which is the nursing homes involved to seek for

permission from its management and explained what the research entailed as well as all the efforts put in

place for ethical practices. Furthermore, after the directors gave permission for the study, the researcher

found the need to go in person to meet all the parking persons and explain about the research and to

answer questions that they may had. More again, all the questionnaires had an introductory letter attached

- 57 -

explaining and giving assurance of participants anonymity and voluntary partake to the study. In

addition, the disclosure of personal identifiable information was not requested for by the researcher. The

respondents were made clearly anonymous. It was made solely for the purpose of carrying out an

academic research

5.5 CONCLUSION

In conclusion, the research study was able to fulfil its obligation of assessing the impact of turnover

on healthcare assistants working across care companies in Dublin. More so, the researcher targeted to

weigh the degree at which a decline in job productivity can be linked to work-related stress among the

HCAs and most importantly, to determine whether staff turnover usually have any detrimental effect on

existing staff and the workplace

However, all the answers to the main objectives and sub research questions were fully attempted. In

summary of the main findings; was that workers felt overburdened with their workload and further noted

that their workload has gotten even more stressful amidst the COVID-19 pandemic. They felt they did not

have a good work-life balance as well as being dissatisfied with their job which were also the main

reasons which they quit or resigned from their jobs. They also stressed on employer-employee

engagement as well as how reoccurring turnover could possibly affect their productivity, morale and

motivation at work. It was further observed that Good pay a couple of other factors might not be enough

to avoid reoccurring turnover. Finally, it is hoped that this piece of study has shed some light on the areas

of turnover and retention strategies as well as their implications and further hope they could be

implemented in private nursing homes as the focus was on them.

5.6 REFLECTION/PERSONAL LEARNING STATEMENT

The research study was about the assessment of employee turnover among healthcare assistants

working for care companies – Dublin. This topic was chosen as the researcher works as a healthcare

- 58 -

assistant in a homecare company. The researcher has also worked in nursing homes in Dublin as a part-

time staff and also as an agency staff. During the period of experience, the researcher noticed that most of

the Healthcare workers not only change work rapidly around the healthcare sector but also quite the jobs

frequently and in large numbers. Also, the author realized during his time in the healthcare sector, there

are lots of shortages across the industry and endless recruitment which fails to meet the demands of the

sector. Hence why the author deemed it necessary, curious and exciting to peruse the research topic at

hand. With the experience of working in the sector, the researcher never realized that there were so many

factors influencing employees to quit their jobs especially in the health sector. The researcher did a lot

research whilst working on the research topic but realized there were more research works done on the

nurses rather than the nursing assistants.

At the beginning stage, it seemed like a change to find the theoretical studies pertaining to only the

healthcare assistants. However, after doing the research structure to be followed, it then seemed the

challenge had been overcome. Throughout the research there were several, mistakes encounter but with

the supervisor’s advice the, mistakes were corrected. As the researcher used quantitative research, there

was much to learn especially the different tools of analyzing the data. One had to be familiar with

different methods and their analysis tools and techniques in order to make the best decision for their

analysis. The researcher found this part challenging but rewarding at the same time. Throughout the

research study, the author felt that she could have explored the SPSS tool and use it for her analysis but

found there wasn’t really need for it as the survey software worked best for her, it didn’t require much

learning and was very easy to use especially with the author’s limited research time. Lastly as the research

study progressed, the author grew confidence with his writings and researching and referencing skills.

- 59 -

APPENDIX 1

QUESTIONNAIRE SURVEY

Section 1

BIO DATA

1. Indicate your age range

18-26 [ ] 27-35 [ ] 36- 44 [ ] 45-53 [ ] 54-62 [ ]

2. What is your gender?

FEMALE [ ] MALE [ ]

3. Indicate your nationality category

Africa [ ] Irish [ ] Other EU [ ] Other [ ]

4. What type of Care Company do you currently work for?

HomeCare [ ] Nursing home [ ]

5. Indicate how long you have been working for this particular care home

0-11 months [ ] 1-2 years [ ] 2-3 years [ ] 3 years or more [ ]

6. Nature of job

Permanent [ ] Casual [ ]

Section 2

IMPLICATIONS OF TURNOVER ON STAFF

7. When an employee leaves, the workload increases

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

8. When an employee has left, it affected my productivity

- 60 -

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

9. When an employee leaves, workplace morale is affected

Strongly Agree [ ] Agree [ ] Uncertain/ Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

Section 3

CONDITIONS AT WORK

10. I have been feeling increasingly unhappy and depressed about my work

Strongly Agree [ ] Agree [ ] Uncertain/ Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

11. I find my job to be very stressful

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

12. My job has gotten more stressful amidst the COVID-19 pandemic

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

13. My level of job satisfaction is low

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

14. I am very concerned by the sheer size of my workload

Strongly agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

15. My level of motivation with this job is high

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

16. My work-life balance has been quite poor

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

17. I have a low level of trust in my employers

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

18. There is a strong organizational culture here

Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

19. There is very little management engagement with my work

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Strongly Agree [ ] Agree [ ] Uncertain/Not Applicable [ ] Disagree [ ] Strongly Disagree [ ]

Section 4

REASONS WHY STAFF MIGHT REMAIN IN A HCA EMPLOYMENT

Please rate these factors using a scale of 0= Not at all important to 5= Very important

Not at all

important

Very important

0

1

2

3

4

5

20. Good pay

21. Favorable workload

22. Good work-life balance

23. Good management support

24. High level of job satisfaction

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REFERENCES

1. Armstrong, M. and Taylor, S. (2017) Armstrong’s handbook of human resource management

practice. 14th edition. London: Kogan page.

2. Allen, D. Bryant, P and Vardaman, M (2010) ‘Retaining Talent: Replacing Misconceptions with

Evidence-Based Strategies’ Academy of Management Perspectives pp: 48-64

3. Aluttis, C., Bishaw, T. and Frank, M. (2014). The workforce for health in a globalized context –

global shortages and international migration. Global Health Action, 7(1), p.23611.

4. Bryant, O. A. (2018). Employee Turnover in the Long-Term Care Industry using Herzberg’s

Motivation-Hygiene Theory. International Journal of Academic Research in Business and Social

Sciences, 8(4), 57–76.

5. Castle, N. G. & Ferguson-Rome, J. C. (2015) Influence of Nurse Aide Absenteeism on Nursing

Home Quality. Gerontologist, 55, 605-615.

6. Cavendish, C. (2013). The Cavendish review: an independent review into healthcare assistants and

support workers in the NHS and social care settings. London: Department of Health.

7. Central Statistics Office, Ireland. (2012a). Irish life tables no.1. (1925-1927). Available at

https://www.cso.ie/en/media/csoie/releasespublications/documents/birthsdm/archivedreports/Irish

Life Table No. 1 1925-1927.pdf. [Accessed 25 January 2018].

8. Central Statistics Office, Ireland. (2018). Population and labor force projections. Available at

https://www.cso.ie/en/releasesandpublications/ep/pplfp/populationandlabourforceprojections207-

2051/2017-2051. [Accessed 25 January 2020].

9. Chang, E., Cohen, J., Koethe, B., Smith, B., & Bir, A. (2017). Measuring Job satisfaction among

healthcare staff in the united states: A confirmatory factor analysis of the satisfaction of employees in

- 63 -

Healthcare (SEHC) survey. International Journal of quality in healthcare, 29 (2), 262-268.

https//doi.org/10.1093/intqhc/mzx012

10. Choi, J., & Johantgen, M. (2012). The importance of supervision in retention of CNAs. Research in

Nursing & Health, 35, 187-199. doi:10.1002/nur.21461

11. CIPD (2002) Training in the Knowledge Economy. London: CIPD

12. Conyard KF, Metcalfe A, Corish S, Flannery J, Hannon P, Rusk B, Yeats S, Codd MB. (2020)

‘Healthcare assistants and qualified carers, A Trained, but untapped underutilized resource: A

population-based study in Ireland’. Dublin: HCA and Carers Ireland & Centre for Support and

Training in Analysis and Research, University College Dublin.

13. Cooke, F. L & Bartram, T. (2015) ‘Guest Editors’ Introduction: Human Resource Management in

Health Care and Elderly Care: Current Challenges and Towards a Research Agenda’. Special issues:

Human Resource Management in Health Care and Elderly Care, 54 (5), pp. 711-735.

https://doi.org/10.1002/hrm.21742.

14. Cooper, R., Donald & Schindler, Pamela, S. (2014) Business Research Methods. 12th ed. Mc Graw

Hill

15. Cowton, C. (1998). The Use of Secondary Data in Business Ethics Research. Journal of Business

Ethics, [online] 17(4), pp.423-434. Available at:

https://link.springer.com/article/10.1023/A:1005730825103 [Accessed 2 Aug. 2020].

16. Daft, R.L. (2014) New Era of Management. 11th edition, South-Western: Cengage Learning London.

17. Department of, H. (2017). Committee on the Future of Healthcare, Sláinte Care Report. Dublin:

Government of Ireland.

18. DOHC (2001) Effective utilization of professional skills of nurses and midwives. Report of the

working group. Dublin: Dublin Stationery Office.

19. Easton, S. & Van Laar, D.L. (2012) User manual of the work-related quality of life scale (WRQoL).

UK: Portsmouth: University of Portsmouth.

- 64 -

20. Estabrooks, C., Squires, J., Carleton, H., Cummings, G., & Norton, P. (2015). Who is looking after

mom and dad? Unregulated workers in Canadian long-term care homes. Canadian Journal of Aging,

34(1), 47–59. doi:10.1017/S0714980814000506McQueen, 2012

21. European Commision and Lanzieri, G. (2011) The greying of the baby boomers. A century-long view

of ageing in European populations, 23 (14), pp. 8 - 12 Available from:

http://www.adapttech.it/old/files/ document/12985eurostat_graying.pdf.

22. Garavan, T., Carbery, R. and Rock, A. (2012) ‘Mapping talent development: definition, scope and

architecture’, European Journal of Training and Development, 36 (1), pp.5-24, Emerald. doi:

10.1108/03090591211192601.

23. Griffeth, W. and Hom, W. (2001). Retaining valued employees. Thousand Oaks, CA: Sage. CIPD

(2014)

24. Gruss, V., McCann, J. J., Edelman, P., & Farran, C. J. (2004). Job stress among nursing home

certified nursing assistants: Comparison of empowered and non-empowered work environments.

Alzheimer's Care Today, 5, 207-216. Retrieved from http://journals.lww.com/actjournalonline

25. Hayes, L., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., Spence Laschinger,

H., & North, N. (2012). Nurse turnover: A literature review. International Journal of Nursing Studies,

49, 887-905. doi: 10.1016/j.ijnurstu.2011.10.001

26. Hayes, T. (2015). Demographic characteristics predicting employee turnover intentions (Doctoral

dissertation). Available from ProQuest Dissertations and Theses. (AAT 1734042628)

27. Herzberg, F., Mausner, B., & Snyderman, B. (1959). The motivation to work (2nd ed.). New York,

NY: Wiley & Sons.

28. Hitt, M., Black, S. and Porter, L. (2014) Management, 3rd edition, Pearson Education International.

29. Hopkins, W.G. (2008) Quantitative research design.

https://www.thefreedictionary.com/junior+school [Accessed on 14 July, 2020].

- 65 -

30. Horn, R., (2009) ‘Research writing and Dissertations’. A complete guide for business and

management students, CIPD: London.

31. International Labor Organization. Updating the International Standard Classification of Occupations

(ISCO) Draft ISCO-08 Group Definitions: Occupations in Health.

32. Jang, Y., Lee, A. A., Zadrozny, M., Bae, S. H., Kim, M. T., & Marti, N. C. (2015). Determinants of

job satisfaction and turnover intent in home health workers. The role of job demands and resources.

Journal of Applied Gerontology, 30, 524-534. doi:10.1177/0733464815586059

33. Kessler, I. (2015). Exploring the relationship between human resource management and

organizational performance in the healthcare sector. Oxford Online Handbooks, April, DOI:

10.1093/oxfordhb/9780199935406.013.13

34. Kessler, I., Heron, P., Dopson, S., Magee, H., Swain, D. & Askham, J. (2010) The nature and

consequences of support workers in a hospital setting

35. Kew, J. and Stredwick, J. (2013) Human Resource Management in a Business Context, 2nd edition.

CIPD: London.

36. Kramer, A. and Son, J., (2016) Who cares about the health of health care professionals? An 18-year

longitudinal study of working time, health, and occupational turnover. ILR Review, 69(4), pp.939-

960.

37. Kumar, S., and Phrommathed, P. (2005). Research methodology (pp. 43-50). Springer US.

38. Lapane, K.L. and Hughes, C.M., (2007) Considering the employee point of view: perceptions of job

satisfaction and stress among nursing staff in nursing homes. Journal of the American Medical

Directors Association, 8(1), pp.8-13.

39. Lee, T.W., Hom, P.W., Eberly, M.B., Junchao (Jason) Li and Mitchell, T.R., 2017. On the next

decade of research in voluntary employee turnover. Academy of Management Perspectives, 31(3),

pp.201-221.

- 66 -

40. Leichsenring, K, Billings, J and Nies, H. (2013) ‘Long-Term Care in Europe’. Improving Policy and

Practice. New York: Palgrave Macmillan; 2013. DOI: http://dx.doi. org/10.1057/9781137032348

41. Masum, A.K.M., Azad, M.A.K., Hoque, K.E., Beh, L.S., Wanke, P. and Arslan, Ö., (2016). Job

satisfaction and intention to quit: an empirical analysis of nurses in Turkey. PeerJ, 4, p.e1896.

42. McCabe, T.J. & Sambrooke, S.A (2018) a discourse analysis of managerialism and trust among

nursing professionals. Irish journal of management, doi:10.2478/ijm-2018-009

43. McGilton, K. S., Boscart, V. M., Brown, M., & Bowers, B. (2014). Making tradeoffs between the

reasons to leave and reasons to stay employed in long-term care homes: Perspectives of licensed

nursing staff. International Journal of Nursing Studies, 51, 917-926.

doi:10.1016/j.ijnurstu.2013.10.015

44. McQueen, E. (2012). Humor-related social exchanges and mental health in assisted living residents

(Doctoral dissertation). Available from ProQuest Digital Dissertations and Theses database. (AAT

299).

45. Muldrew, D., McLaughlin,D., & Brazil, K (2 018). Ethical Issues Experienced by Healthcare

Workers Providing Palliative Care in Nursing Homes: A Mixed Methods Study. Palliative Medicine,

32 (1_Suppl). https://doi.org/10.1177/0269216318769196

46. Murphy (2020). Covid-19 and Healthcare Workers. Irish Medical Journal of Nursing Issue: Ir Med J;

Vol 113; No. 5; P67

47. NHS Scotland (2010) A guide to healthcare support worker education and role development.

48. Norris, M. J. (1990) The SPSS Guide to Data Analysis for release. Chicago: SPSS Inc.

49. Norris, J.M., Ross, S. and Schoonen, R. (2015). ‘Guidelines for reporting quantitative methods and

results in primary research’. A Journal of Research Language Studies, 65(2), pp. 470-476.

50. Pace, V. and Kisamore, J. (2017), “Strategic exit interviewing: encouraging voice, enhancing

alignment and examining process”, Journal of Organizational Effectiveness: Peopleand Performance,

1(4), pp. 59-75, doi: 10.1108/JOEPP-03-2016-0023.

- 67 -

51. Perreira, T. A., Berta, W. and Herbert, M. (2018) ‘The employee retention triad in health care:

Exploring relationships amongst organizational justice, affective commitment and turnover intention.

Journal of clinical nursing. https://doi.org/10.1111/jocn.14263

52. Philbream, S. and Corbridge, M. (2006) People resourcing: contemporary HRM in practice. 3 rd

edition. Pearson Educational Limited. Spain and Groysberg (2016) “Making exit interviews count”.

Harvard Business Review, 4 April.

53. Taylor, C. (2014) “Workers still slow to embrace flexible working arrangements”. Irish times, 28

November.

54. Taylor, R. (2004) “Skills and innovation in modern workplaces”. ESRC Future of Work Program

Seminar Series. Leeds University.

55. Taylor, S. (2002) Employee retention handbook. London: CIPD.

56. Taylor, S. (2014) Resourcing and talent management, 6th edition, London: CIPD.

57. Pélissier, C.; Fontana, L.; Fort, E.; Vohito, M.; Sellier, B.; Perrier, C.; Glerant, V.; Couprie, F.;

Agard, J.P.;

58. Philbream, S. and Corbridge, M. (2006) People resourcing: contemporary HRM in practice. 3rd

edition. Pearson Educational Limited.

59. Pratt, J. R. (2010). Long-term care: Managing across the continuum. Sudbury, Mass: Jones and

Bartlett Publishers.

60. Price, A. (2004) Human Resource Management in a Business Context. 2nd edition. London: Thomson

learning.

61. Rubenstein, A.L., Eberly, M.B., Lee, T.W. and Mitchell, T.R., (2018). ‘Surveying the forest: A

meta‐analysis, moderator investigation, and future‐oriented discussion of the antecedents of voluntary

employee turnover’. Personnel Psychology, 71(1), pp.23-65

- 68 -

62. Saks, M., Allsop, J., Chevannes, M., Clark, M., Fagan, R., Genders, N., Johnson, M., Kent, J., Payne,

C., Price, D., Szczepura, A. & Unell, J. (2000) ‘Review of Health Support Workers, Report to the UK’

Departments of Health. Leicester: De Montfort University.

63. Sanford, A.M., Orrell, M., Tolson, D., Abbatecola, A.M., Arai, H., Bauer, J.M., CruzJentoft, A.J.,

Dong, B., Ga, H., Goel, A. and Hajjar, R., (2015) ‘An international definition for “nursing home’.

Journal of the American Medical Directors Association, 16(3), pp.181184.

64. Cheloni, S and Tinker, A. (2019) ‘Working with older people with dementia: motivation and

demotivation among Health carers’, Working with older people, 23 (3), pp. 117 – 126.

doi:10.1108/WWOP-04-2019-0007

65. Saunders, M., Lewis, P. and Thornhill, A., (2009) Research Methods for Business Students. 5th ed.

Essex: Pearson Education Limited.

66. Saunders, M., Lewis, P. and Thornhill, A., (2012) Research Methods for Business Students. 6th ed.

Essex: Pearson Education Limited.

67. Schwendimann, R., Dhaini, S., Ausserhofer, D., Engberg, S. and Zúñiga, F., 2016. Factors associated

with high job satisfaction among care workers in Swiss nursing homes–a cross sectional survey study.

BMC nursing, 15(1), p.37.

68. Smith, S., Murphy, E., Hannigan, C., Dinsmore, J. & Doyle, J. (2019) ‘Supporting older people with

multimorbidity: The care burden of home health-care assistants in Ireland. Journal of Home Health

Care Services Quarterly,8 (3), 241-255. https://doi.org/10.1080/01621424.2019.1614506

69. Spilsbury, K., Pender, S., Bloor, K., Borthwick, R., Atkin, K., McCaughan, D., Watt, I., Adderley, U.,

Wakefield, A. and McKenna, H. (2013). Support matters: a mixed-methods scoping study on the use

of assistant staff in the delivery of community nursing services in England. Health Services and

Delivery Research, 1(3), pp.1-146.

- 69 -

70. Roberts LW, Berk MS, Lane-McKinley K. (2019) Ethical Considerations in Research on Suicide

Prediction: Necessity as the Mother of Invention. JAMA Psychiatry, 76(9):883–884.

doi:10.1001/jamapsychiatry.2019.1228

71. Wall, M. (2018). Siptu to seek pay rises for healthcare assistants, conference told. [online]

72. The Irish Times. Available at: https://www.irishtimes.com/news/health/siptu-to-seek-payrises-for-

healthcare-assistants-conference-told-1.3651923 [Accessed 22 July, 2020].

73. Thimbleby H. (2013). Technology and the future of healthcare. Journal of public health

research, 2(3), e28. https://doi.org/10.4081/jphr.2013.e28

74. Uduma, I. & Sylva, W. 2015. A critique of the adequacy of positivist and interpretivist views of

organisational studies for understanding the 21st century organization(s). International Journal of

Business and Management Review, 3(8):44-52.

75. UNISON (2016) Care on the Cheap: A UNISON survey of clinical support workers. London:

UNISON.

76. Van Eenoo, L, van der Hout, H, Declercq, A. (2016) ‘Quality of Care and Job Satisfaction in the

European Home Care Setting: Research Protocol’. International Journal of Integrated Care, 16 (3),

p.14. doi: http://doi.org/10.5334/ijic.2519.

77. Wall, M. (2019). Siptu warns of nursing shortage at new children’s hospital. [online] The Irish Times.

Available at: https://www.irishtimes.com/news/ireland/irish-news/siptuwarns-of-nursing-shortage-at-

new Nursing Homes Ireland. (2019).

78. Winter, G., 2000. A comparative discussion of the notion of 'validity' in qualitative and quantitative

research. The qualitative report, 4(3):1-14.

79. Woodhead, E. L., Northrop, L., & Edelstein, B. (2014). Stress, social support, and burnout among

long-term care nursing staff. Journal of Applied Gerontology, 1-22. doi:10.1177/0733464814542465

80. Zhang, N. J., Unruh, L., & Wan, T. T. (2013). Gaps in nurse staffing and nursing home resident

needs. Nursing Economics, 31, 289-297. Retrieved from http://www.nursingeconomics.net

- 70 -

81. Zhang, Y., Punnett, L., & Gore, R. (2014). Relationships among employees’ working conditions,

mental health, and intention to leave in nursing homes. Journal of Applied Gerontology, 33, 6-23.

doi:10.1177/0733464812443085